Preprint:

Please note that this article has not completed peer review.

Exploring women’s perceptions of pain when

breastfeeding using online methods
CURRENT STATUS: POSTED

Line Caes
University of Stirling

line.caes@stir.ac.ukCorresponding Author
ORCiD: https://orcid.org/0000-0001-7355-0706

Katie Abbott
University of Stirling School of Natural Sciences

Sinead Currie
University of Stirling School of Natural Sciences

DOI:
10.21203/rs.2.15976/v1
SUBJECT AREAS
Maternal & Fetal Medicine
KEYWORDS
Breastfeeding, Pain, Women, Infant Feeding, Experiences.

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Abstract
Background: Despite benefits, many mothers stop breastfeeding soon after birth. A common reason

for this is the experience of pain or discomfort. One resource which women use to share their

breastfeeding challenges and seek support are online forums. This study aimed to collect data from

online forums to explore 1) usage of forums as social support for breastfeeding related pain;

2) experiences of breastfeeding related pain; 3) perceptions and strategies to deal with breastfeeding

related pain; and 4) the impact of pain on breastfeeding duration.

Methods : This secondary analysis of data involved searches of online forums: Netmums, What to

Expect and Mumsnet using key terms including ‘ painful breastfeeding’ and ‘sore breastfeeding’ .

Data included 123 posts and 193 replies, which were analysed using thematic analysis.

Results: The first theme identified was ‘variation in types of pain’, highlighting the variety of painful

experiences and their descriptions. Secondly, ‘perceived causes and explanations for pain’ revealed

pain ascribed being due to a recognised condition or behavioural cause. The third theme ‘cessation of

breastfeeding related to pain’ identified both physical and psychological struggles related to

breastfeeding and cessation. Finally, ‘shared experiences and support’ identified practical or

emotional support to deal with pain.

Conclusion: Pain was a key reason for breastfeeding cessation, commonly associated with strong

feelings of guilt. The online forums provide a unique form of social support for breastfeeding women

to find ways to cope with the pain, while highlighting the urgent need for more appropriate antenatal

education on realistic expectation surrounding breastfeeding.

Background
It is well recognised that breastfeeding is beneficial for infants as well as mothers. Compared to being

formula fed, babies who receive breastmilk have better immune protection, nutrition, regulation of

growth development and reduced risks of future obesity and respiratory infections [1,2]. Furthermore,

mothers who breastfeed their babies are at reduced risks of breast cancer, ovarian cancer and type 2

diabetes [3]. Despite the benefits of breastfeeding, literature from many European countries,

including the UK, indicates low breastfeeding initiation and duration rates which often do not adhere

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to the World Health Organisation recommendations which includes exclusive breastfeeding for the

first six months of an infant’s life [4,5]. For example, in Scotland it is estimated that 53% of mothers

are exclusively breastfeeding at hospital discharge and only 37% are exclusively breastfeeding at 6

weeks after birth. When considering any breastfeeding (exclusive and mixed feeding) 69% of women

are providing breastmilk to their babies on discharge from hospital, 55% are providing some

breastmilk at 6 weeks after birth and 43% are providing some breastmilk at 6 months after birth [6].

Hence, there is a noticeable decline in provision of breastmilk over the first 6 months of an infant’s

life, with the steepest decline in exclusive breastfeeding within the first 6 weeks of life. There are

many hypothesised reasons for the decline in breastfeeding duration rates, however, one

predominant barrier to breastfeeding duration, which women commonly cite, is nipple and breast pain

[7, 8, 9].

The experience of pain associated with breastfeeding can differ between individuals, with some

women reporting intolerable pain and others reporting mild discomfort [10,11]. However, this

unappealing feeling, no matter how extreme, can be highly detrimental to the breastfeeding

experience. Experiences of pain or discomfort have been strongly linked with breastfeeding cessation

and this pain-associated cessation is associated with feelings of guilt, dissatisfaction, upset and

increased risk of post-natal depression [11]. Even in the most determined mothers who have a strong

intention to breastfeed, pain is often cited as a key reason for cessation [12].

Whilst it is confirmed that pain and/or discomfort is a common factor experienced during early days of

establishing breastfeeding, the underlying reasons for these experiences of pain and how women

manage this experience, are varied [13], and not well understood [14]. There is conflicting literature

surrounding reasons for pain or discomfort associated with breastfeeding. Often, nipple-pain is

attributed to the incorrect positioning of the baby [15], however, there is evidence which refutes this

link. Blair et al. (2003) concluded that neither head position nor body position was more related to the

level of pain experienced by the mother, suggesting that there may be other physiological or

psychological reasons why women commonly experience nipple pain [16]. Furthermore, research has

mostly focused on the experience of nipple pain, with little known about the specific type or range of

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pain women experience when breastfeeding.

Beyond understanding the reasons for and range of pain experiences, it is important to consider how

women can be supported to manage or cope with pain whilst breastfeeding. Qualitative research

indicates that women express a mismatch between their general expectations and realities of

breastfeeding [17] as well as a lack of support for emotional needs related to breastfeeding [18]. Yet

many women prefer social support over healthcare professional support and they recognise that other

people such as family and friends can strongly influence their breastfeeding expectations and

experiences, both in a positive and negative manner [19, 20, 21]. Although some studies highlight

how peer counselling increases breastfeeding initiation, none of the antenatal breastfeeding

education programme evaluated in a recent Cochrane review could be recommend due to substantial

methodological limitations [22]. Additionally, there is little exploration of what women expect in

relation to pain during breastfeeding or exactly how others help or hinder coping with breastfeeding

pain [23].

Although online methods are now recognised as a key source of health information and social support

for both parents and health professionals [24], this remains an untapped source to advance our

understanding of breastfeeding pain experiences and support needs. Specifically, pregnant and

postnatal women often seek health information and peer support from online groups and social media

[21, 25). A range of studies have specifically explored the use of online social media and social

networking as a tool for parenting or breastfeeding peer support. The literature indicates that women

actively use online social media and social networking to source breastfeeding information as well as

emotional and practical support [26, 27]. Hence, these social media platforms provide a sense of

community to these women, who are sharing similar experiences.

The aim of the current research is utilise online chat forums to explore 1) women’s use of online

forum for seeking social support regarding pain or discomfort associated with breastfeeding 2)

women’s experiences of pain or discomfort associated with breastfeeding; 3) women’s perceptions

and strategies for dealing with pain or discomfort; and 4) how pain or discomfort may influence

women’s decision to (dis)continue breastfeeding.

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Methods
Study Design
A secondary analysis of online data from discussion forums was conducted. Ethical approval was

sought and granted from the General University Ethics Panel, University of Stirling.

Selection of Website Discussion Forums

Google was used to search for websites which contain discussion forums in which individuals can

freely post any comments related to breastfeeding. Websites were found using the following search

terms: ‘parents online forums’, ‘parenting forums similar to Netmums’ and ‘most popular parenting

forums’. Three websites with discussion forums were selected and used for data collection. Two were

UK based; Netmums [28] and Mumsnet [29] and one was USA based; What to Expect [30]. The three

websites were chosen based on their diversity (UK and USA based) and popularity (each website had

a range of forums with a high quantity of relevant posts). On all included website discussion forums,

any individual can join and make a post which is visible to anyone accessing the forum. All three

website administration/customer service teams were contacted via email in order to seek permission

to anonymise and analyse the data available on the chat and discussion pages.

Identifying Relevant Posts from Discussion Forums

Word searches were conducted on each of the website discussion forums using the keywords ‘Pain’,

‘Breastfeeding’, ‘Painful Breastfeeding’ and ‘Sore Breastfeeding’. These searches resulted in the

identification of posts which contained the keyword searched for. Word searches of discussion forums

were conducted in July 2018 in Stirling, Scotland by one researcher (KA).

Post Selection
Each post identified from the word searches were read in the order they were displayed. Inclusion

criteria for a post to be included in analysis was (1) written in English, (2) focuses on challenges

related to painful breastfeeding and (3) written by the individual explaining their experience. All

identified posts were read thoroughly to ensure they met these criteria. All replies to the post were

read and included in analysis.

A total of 123 posts were identified from the word searches, which were made between 2012 and

2018. All 123 posts were eligible for inclusion and analysis. A total 193 reply comments accompanied

those post, resulting in a total of 316 data extracts included in the analysis.This included 146 data

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extracts from What to Expect, 89 from Mumsnet and 81 from Netmums.

Data Extraction
One research assistant (KA) conducted the data extraction of the final list of data extracts in July

2018. The information extracted included 1) the link for the post on the website, 2) whether a post

was original or a reply, 3) the date of which the post was submitted to the forum, 4) full text of the

post. As no pre-existing framework on breastfeeding pain is available, the stages of inductive

thematic analysis were followed to analyse all selected posts to answer the research questions.

Firstly, in order to familiarise with the data, the researcher read through all posts in detail numerous

times, at this stage no interpretations were made. Secondly, to generate a better understanding of

the data, the RA generated 25 codes to represent the data. Thirdly, both the senior authors (SC and

LC) and the researcher analysed the codes and produced four main themes. Fourthly, the researcher

reviewed all the data extracts using the four identified themes to ensure that the themes were fully

representative of the data. Fifthly, after generating a thematic map of the data, both senior authors

and the researcher defined and named the themes and finally key quotes were selected to best

represent each theme.

Results
The inductive thematic analyses resulted into four themes and a range of sub-themes (see Table 1).

Variation in types of pain

The first theme generated from the data was ‘variation in types of pain’. This theme represents the

large variety of different types of pain women explain and experience at different stages throughout

their breastfeeding journey. Furthermore, the various ways in which women describe these pain

experiences highlights how women differ in the way they describe pain, ranging from descriptions

focussed on the pain location, to the sensory or emotional characteristics of pain to the physical

process the pain is associated with. Across these three types of descriptions, a total of seven distinct

types of pain women experience in relation to breastfeeding could be identified.

With respect to descriptions focussed on pain location, a large number of posts mentioned the

experience of painful nipples, with some post referring to the general feeling of sensitive or sore

nipples while others refer to the more specific experience of cracked nipples:

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‘My nipples have been blistered, I’ve been using cream and when not using that using nipple healing

cups. One nipple is still really sore but seems to be healing and the other is still a bit sore’ (P1

Mumsnet, post).

‘I am cracked, bleeding, blistered and even wet myself yesterday with the pain of it. I am alternating

between biting a towel stamping my feet and making moaning noises’ (P2 Netmums, post).

However, for a substantial number of women the experience of pain is not limited to the nipples and

encompasses the entire breast, even without any specific nipple damage.

‘for almost a week now I’ve had really sore breasts, particularly in the evening to the point! There is

no damage to my nipples, the pain is in my actual breasts. They are hot and the pain is like a burning

pain’ (P3 Netmums, post).

In terms of the sensory aspects of the pain associated with breastfeeding, women often described the

experience as ‘sharp shooting pain’ that could be felt in the breast but also the larger area around the

breast, including the shoulders. For some women, this description also had an emotional layer as they

experienced the pain occurring randomly and unexpected, especially when the pain occurred months

after they have been breastfeeding. Such an unexpected occurrence of pain could be induced by

unrealistic expectations women posit around breastfeeding.

'sharp shooting pain in my shoulder blade behind the breast the is baby feeding on’ (P4 Netmums,

post).

'So I have been breastfeeding for 8 months and randomly (when I’m not nursing) I get a shooting

sharp pain in my breast… any clue what it could be??’ (P5 What to Expect, post).

Lastly, women also described their pain in terms of the physical process it was related to, with the

two most common processes being ‘let down’ and ‘latch’. Let down pain relates to a type of pain that

occurs when milk is beginning to flow and typically occurs in the first few weeks of breastfeeding.

‘Just wondering if you had let down pain when breastfeeding and if so for how long, my son is 3 weeks

old today and the pain at initial latch on is excruciating’ (P6 Netmums, post).

A painful latch is pain related to how the baby latches on to the nipple and occurs when the baby

does not properly latch onto the mother’s breast.

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‘Sometimes, (mostly on the ‘bad’ side) it can be absolutely excruciating for the whole feed’ (P7

Mumsnet, post)‘.

Perceived causes and explanations for pain

The second theme focuses on women’s interpretations and perceptions of pain during breastfeeding

as well as the interpretations and perceptions given by other users who are replying to the original

post. In line with the commonly observed application of the biopsychosocial model of pain which

primarily focusses on biological and psychological causes of pain experiences and largely ignoring the

contribution of social factors (Craig, 2018), the perceived causes and explanations for breastfeeding

pain experiences can be divided into ‘recognised conditions’ (i.e. biological explanation) and

‘behavioural explanations’ (i.e. psychological explanation).

As a first sub-themes, recognised conditions include conditions such as mastitis, thrush, raynauds

syndrome or tongue tie, which are all known to be associated with pain. Many women spoke of their

familiarity with these recognised conditions, where they commented on their personal experience:

‘Recently we have had mastitis, it is painful and I came very close to stopping feeding him as I was

just in tears everytime I fed him’. (P8 Netmums, reply).

The posts went beyond providing suggestions on the causes, with some women also giving advice on

how they dealt with the condition they were faced with:

‘It could be thrush! I took her to the doctor and he saw some hidden patches behind her gums. I rub a

gel in her mouth and on my nipples twice a day and it seems to be helping’ (P9 What to Expect,

reply).

This type of feedback from others on the discussion forum allows the women who are suffering these

problems to feel that they are not alone in what they are experiencing and that these types of

conditions throughout breastfeeding are common.

The second sub-theme reflects the behavioural explanations defined as any behavioural cause,

reason or solution given for pain during breastfeeding. Examples include, the latch position of the

baby and various ways to clear blocked ducts (which can cause pain). Most of the suggestions for

behavioural causes came from other users replying to original comments made by mothers looking

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for help and advice about certain types of pain. Similar to the post providing a recognised condition

as an explanation for the pain, these posts often went beyond describing the cause and also provided

potential ways of coping with the pain:

'Sounds like a clogged duct. Use a hot compression before you feed or pump. Apply coconut oil and

massage the area while baby nurses or you pump. Push on area that feels hard/hot and push towards

nipple. When you shower use the hottest water you can and massage some more.’ (P10 What to

Expect, reply).

‘the attachment and positioning will most probably be the problem for the pain when latching on. Def

ask hv to watch you when you feed. I always tell mums to remember: Tummy to Mummy, (babies)

Nose to Nipple and keep the head and body in a straight line’. (P11 Netmums, reply).

This type of advice allows the mothers who are experiencing difficulties to self-help, where they can

try out new techniques themselves before having to make an appointment to see other health

professionals.

Cessation of breastfeeding related to pain

The third theme, ‘cessation of breastfeeding related to pain’ encompasses the pain related reasons,

struggles and psychological consequences women mention in relation to stopping, or considering

stopping, breastfeeding. Similar to the second theme, the identified struggles women report on pain-

related breastfeeding cessation can be divided into physical and psychological aspects.

Physical reasons and struggles mainly referred to the how the breastfeeding experience is extremely

painful in the first few weeks due to breasts and nipples adapting to feeding, again indicating there

may be some unrealistic expectations regarding the breastfeeding experience. Women replying to

cessation-related comments within original posts made by others often provided comfort to other

women by reassuring that the pain they are experiencing may not necessarily be caused by

something they are doing wrong, or any medical conditions but instead just because their body is

adapting to the change it is facing.

'Your nipples are tender at first so, imagine going from not having anything touching your nipples, to

having a baby latched on every two hours for 30 minutes or more at a time WHILE your nipples are

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already tender and hurting from the hormones of having a baby’. (P12 What to expect, reply).

A common, recurring theme across all forums reflected the psychological struggles or consequences

women experience when considering breastfeeding cessation, with a considerable number of women

reporting feeling guilty:

'I feel a total failure on this, and I don’t want to give up, but it’s being so hard and painful. I also feel

guilty because I find myself wishing it to end soon, I mean wishing the time going faster until the

point that she’s 2 years and I can stop breastfeeding and I feel like such a terrible mom’. (P13 What to

Expect, post).

The psychological side of breastfeeding indicates how difficult it can be for mothers to cope with the

pain they are facing and how they experience feelings of guilt or sadness about possibly quitting

breastfeeding earlier than recommend, as they know it is beneficial for their baby. A commonly

reported strategy to overcome feelings of guilt while managing the pain was the use of breast pumps.

Indeed, many women reported making use of breast pumps as a compromise to reduce the pain and

continue providing the baby with breast milk without having to endure the pain of breastfeeding,

which helps them to not feel guilty about providing their child with breast milk:

'If you are in pain, you can pump or hand express to relieve the pressure’. (P14 Mumsnet, reply).

Shared experiences and support

The final theme ‘shared experiences and support' represents the range of support and knowledge

exchange that women offer throughout the forums. The sub-themes include sharing experiences;

practical support and experience and; support from health professionals.

Many mothers offer, through the replies, their own experiences of breastfeeding in order to help other

women and provide emotional support:

‘Most importantly is your well being—healthy Mum = healthy baby no matter how she is fed, it makes

no difference, you can’t look at a room of adults and tell who was BFd and who wasn’t. Please seek

help if you wish, or continue with formula and relax and enjoy this precious gift of a child without

guilt. Sending unmumsnetty hugs. Also remember you’re under massive hormonal influences at the

moment and so everything will be feeling magnified’. (P15 Mumsnet, reply).

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From the data, it is evident that many women who post an original post are not looking for specific

reasons of why they are experiencing pain but instead they are looking for emotional support and to

know that other women have faced similar experiences to them.

In addition to emotional support, many women also offer each other practical support for reducing

pain. This includes recommending a range of medications or creams or offering advice on different

latching techniques, this support is shown in the following quotation:

‘Aim you nipple to the back of babies mouth (in most cases this is enough to get enough in for a good

latch, as the pink area will go in also 2). If you still have pain, take baby off by using your little finger

next to your nipple so baby looses grip.. and try again until you have minimum of pain( I cant say

completely no pain right now, as you nipples are sore), but the pain you will very minimum, if nothing

at all, and if it is correct, no pain at all within a few days’. (P16 Netmums, reply).

Finally, this theme covers the mothers’ perceptions of health professionals and their ability to deal

with pain during breastfeeding and offering guidance and support to women. Many women have

different opinions on health professional’s ability to deal with the problem. For example, some women

felt that midwives and other professionals offer false hope in saying breastfeeding should be a pain-

free experience:

'I am baffled by the unrealistic advice given to pregnant women about breastfeeding by health

professionals- If it hurts you are doing it wrong. 99% of women can successfully breastfeed. I

understand their role is to encourage women to do it but surely being honest about the difficulties of

starting that many women encounter would be more helpful. Mothers who then have difficulty are left

feeling they’ve failed when they are trying to pick up the pieces. Likewise problems may not get as

bad if we were honest to women about it’. (P17 Mumsnet, post).

On the other hand, some women reported positive experiences with different health professionals

who helped with advice and support through their difficult time of breastfeeding, for example one

user had a positive experience with their midwives:

‘Have been seeing midwives everyday for extra support which is fab and have now been referred to

the breast feeding expert and also GET THIS been referred to see the TONGUE TIE consultant!’ (P18

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Netmums, reply).

Both of these quotations reflect the different experiences that mothers can have with different health

professionals, highlighting the importance of having good training in place for these professionals to

be able to recognise and deal with, different types of medical conditions or behaviours that can cause

mothers to have a bad experience with breastfeeding.

Discussion
Using thematic analysis to gain an insight in the pain women experience during breastfeeding and

how online forums are being used to share experiences, four main themes were identified: variation in

types of pain, perceived causes and explanations for pain, cessation of breastfeeding related to pain;

and shared experiences and support. These findings closely match to and extend the findings for a

recent qualitative study by on early breastfeeding cessation [18]. Using semi-structure interviews in

15 first-time mothers, these authors identified that pain was the main reason for early cessation,

associated with ambivalent feelings of physical and psychological causes and consequences. Similar

to the stories from the online forums, these women [18] reported varying experiences of support from

healthcare professionals, with most receiving inadequate information. Our findings expand on this

knowledge by providing a more detailed insight in the various experiences of pain and associated

perceived causes, as well as how many women seek and receive social support for these experiences

on online forums.

With respect to the types of pain, our findings align with previous results revealing the considerable

prevalence of pain experiences during breastfeeding, with nipple pain being commonly reported [10,

11, 27]. However, our findings reveal a large variety of pain experiences women struggle with during

breastfeeding. It was particularly noteworthy how detailed the women on the forums described their

pain experiences, which allows for an understanding of exactly what they are facing and how common

it is to experience certain types of pain. A better understanding of the various types of pain

experienced during breastfeeding is critical in designing appropriate interventions to manage the pain

experience. Intervention development has so far mainly focused on the experience of nipple pain

[27], which might not be appropriate for other common pain experiences, such as the sharp shooting

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in the breast, painful latch or let down pain. Such detailed understanding might not have been

established using more traditional research methods, which face the challenge of selection bias in

whom participates as well as bias in self-report and not providing an accurate reflections of the ways

people communicate in daily life [31]. In contrast, online discussion forums have the ability to reach a

larger number and variety of people and lack the steering by the researcher’s interests/orientation,

thereby allowing forum users to drive the focus of discussions. For instance, within the second theme

comes an interesting understanding of individual’s perceptions of pain, from both the user who

publishes an original post but also users who are replying to these posts. While we cannot be sure

that the perceptions of cause for the pain overlap with the actual cause, these findings do contribute

to further our understanding that both behavioural and biological reasons can be evident [10, 32].

Consequently, online forums have the potential for users to share and attain real-life experiences and,

therefore, set realistic expectation about the potential pain, and underlying cause, that can be

experienced during breastfeeding. Indeed, throughout this research, and apparent from previous

findings, online forums and social media have become an intrinsic method of communication and

social connection for our current generation of parents. Whereby, it is easily accessible at any point of

the day, and provides a realistic insight, a sense of community and a way of making new contacts

[26]. However, not much research has been conducted concerning ungoverned online forums,

therefore, further investigations will be needed to evaluate the potential impact for helping users to

cope with pain and breastfeeding continuation.

The remaining two themes point to the two common aspects within the user’s experiences that

deserve more attention: the role of peer support and setting realistic expectations on the experiences

of pain during breastfeeding. These findings link in well with existing qualitative work [21], where

authors evaluated the experiences of women attending Baby Café Breastfeeding support groups.

Their finding identifies the need for realistic, not idealistic, expectations and preparations antenatally

on breastfeeding and how social support groups, delivered in combination with guidance from

healthcare professionals, could contribute to such normalisation of mixed experiences with

breastfeeding [21]. However, not all women might feel confident enough to attend face to face

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support groups, a barrier that is less prominent on anonymous online forums. Indeed, all of the

forums were extremely interactive, with users being very open about posting their pain experience

and receiving various suggestions from others on what the cause could be or how to deal with the

pain, based on their own lived experiences. Such support by someone who has dealt with a similar

experience can be comforting for the individual and provide them with the confidence to resolve their

issue (either by themselves or by seeking formal help) [33]. Indeed, the content of the fourth theme

revealed that receiving emotional support from other users is commonly observed. This emotional

support is linked highly to the psychological side of breastfeeding struggles, for example feelings of

guilt as reflected in the third theme, where many users just want to know that someone else has been

through a similar situation to them and that they made it through that difficult time. As found in

previous research [18, 21, 34], it is very common for women to feel guilty for wanting to quit as they

knew how beneficial breastfeeding was for their baby, so it made them feel like a failure by

preventing their baby from being provided with these benefits. This strong prevalence of the guilt

feeling highlights how women are aware of the and convinced by the benefits of breastfeeding, which

may suggest that information provision surrounding the benefits of breastfeeding may not actually be

an effective strategy to support breastfeeding continuation. These findings further support the recent

research [34], which highlights how appropriate support for these guilt feelings is crucial in

preventing mental health difficulties in women such as prolonged breastfeeding grief and advocates

for a re-evaluation of how breastfeeding is being promoted.

Consequently, the findings indicate that psychological support, such as peer support, is crucial in

overcoming the psychological impact of pain experiences during breastfeeding in order to facilitate

breastfeeding continuation. An important aspect of this peer support observed in our data was aimed

at providing reassurance on how it is okay to use breast pumps to provide their child with the benefits

from breast milk while giving mother’s the opportunity to cope with the pain. The availability of peer

support can be crucial for mothers to keep a healthy mind while looking after their child(ren). It allows

them to speak to one another and provide comfort to each other. This is an unique type of support

that women can give each other that goes beyond the care and support received within a formal

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healthcare setting [33] and strongly reduces the feelings of isolation (I am not the only one feeling

this!). Although it needs to be acknowledged that the support provided by peers might not always be

accurate and credibility of the sources needs to be considered carefully [35], the availability of such

peer support outside the context of the healthcare system could reduce the reliance on healthcare

professionals from postnatal women due to the signposting from other women before deciding if

formal help form healthcare professionals needs to be sought [36]. One study exploring the impact of

peer support for breastfeeding [33], found that a telephone-based peer support programme for

breastfeeding resulted in retaining high numbers of exclusive breastfeeding practices 3 months

postpartum, which was also associated with higher satisfaction with the infant feeding experience.

While further research is needed to establish this impact of peer support in the context of

breastfeeding pain [22], the beneficial impact of peer support on individual’s self-management

confidence and ability as well as reduced distress due to pain has been well established within the

context of chronic pain experiences [37].

With respect to setting realistic expectations, our findings indicate how many users were unaware

that the experience of pain during breastfeeding is quite common. Many users on the forum who

replied to original posts advised that it does in fact take a short while (i.e. a few weeks) for your

breasts to adapt to breastfeeding, as it is a new experience for both the mother and baby. The

widespread sharing of just how common pain experiences are in the first six weeks can have a strong

normalising effect for women and can provide a sense of comfort and relief to other users who are

thinking of quitting breastfeeding in the first few days. Consequently, such normalisation allows them

to feel that things will get better over time, which might be enough to encourage them to continue

breastfeeding. In line with the benefits of including realistic expectation setting within antenatal

interventions to reduce anxiety and depression in new mothers, [38], setting realistic expectations

around pain symptoms during breastfeeding may be beneficial for both antenatal and postnatal

women.

The relevance to set realistic expectations for breastfeeding and potential pain experience also came

to light in users’ sharing of their personal opinions of health care professionals. In accordance with

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previous qualitative evidence [18], the forum posts revealed mixed views on the helpfulness of the

health professionals and their ability to provide relevant care. Some users felt they did not focus

enough on breastfeeding being painful, so it came as a surprise when it was painful and subsequently

increased the worry for the women and their likelihood of quitting. In line with our suggestion above

for setting realistic expectations during pregnancy, many users indicated the need to pay more

attention to the fact that breastfeeding can be painful, but this pain can be seen as a normal process

where the body is adapting to certain changes. Due to the lack of awareness that it is common for

breastfeeding to be painful in the first few weeks, many users felt that they were doing something

wrong if they felt pain during breastfeeding, or that there was something medically wrong with them

because they were experiencing pain. On the other hand, several users did comment on their positive

experiences with health professionals, giving them credit for being supportive and getting to the

bottom of their issue. Raising awareness of breastfeeding pain requires optimal communication skills

and hence these mixed experiences with healthcare professional highlight the need to provide

healthcare professionals with appropriate support on how to convey the normal experience of pain

during breastfeeding without scaring mothers and thereby jeopardizing either the start or

continuation of breastfeeding.

Our findings need to be considered in light of some limitations. Although online forums provide a rich

and varied amount of lived experience, there is no information available on the demographics of the

forum users. While selection bias might be less of an issue compared to more traditional research

methods, research on online forum users highlighted inequalities amongst users. Indeed, previous

literature [23] illustrates that there are substantial differences in those who use online parenting

forums due to gender, age and socio-economic status. Consequently, mothers who use online forum

might not be representative of the entire population. Furthermore, while the posts typically provided

detailed descriptions of women’s experiences, this medium does not allow for exploration of relevant

aspects of the experiences in further detail (for example, how did the replies influence their emotions

and behaviour). Consequently, further research is needed to explore the impact of online forums on

women’s experiences and breastfeeding continuation as well as the underlying mechanisms of such

16
benefit.

Conclusion
Despite the limitations, our findings have relevant clinical implications. In order to increase the

number of women choosing to breastfeed or increase the length of time women breastfeed for,

interventions should set realistic expectations on the common types of pain experienced. These

interventions should bring a focus to the different types and causes for pain such as thrush, or

mastitis and what self-management techniques can be implemented to reduce the pain, such as hot

compressions or specific creams to reduce pain. Furthermore, raising awareness of when to seek

professional help for pain experiences, is also crucial. In line with interventions for other types of

acute pain (for example, vaccinations or injury), it is important to address the psychological struggles

within interventions aimed at managing breastfeeding pain. In particular, the findings reveal that it is

important to make women aware of the psychological impacts of pain (i.e. guilt feelings) and are

provided with coping mechanisms to overcome these feelings (for example, cognitive restructuring).

Health professionals should begin to integrate realistic expectations of breastfeeding pain in their

appointments, however, should provide means of how you resolve the common health problems that

the expecting mother may face. This could help to reduce the worry if or when the women experience

any of these common types of pain. Our findings provide preliminary, but promising, evidence for the

potential role of (online) peer support to encourage sharing breastfeeding struggles and the

emotional impact and provide a normalisation, to women who are struggling to keep going.

Declarations
Ethical approval: Ethical approval was granted from the General University Ethics Panel, University of

Stirling.

Consent for publication: Not Applicable

Availability of data and materials: The datasets used and/or analysed during the current study are

available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: The authors would like to thank and acknowledge The Carnegie Trust for the Universities of

17
Scotland who funded this project through their Carnegie Vacation Scholarship scheme.

Author’s contributions: KA gathered, analysed and interpreted the forum posts and replies. LC and SC

analysed the codes generated by KA and produced four main themes, in collaboration with KA. All

authors contributed to writing the manuscript, with each author taking responsibility of a section and

LC being responsible for the integration of all sections. All authors read and approved the final

manuscript.

Acknowledgments: Not Applicable

References
1. McFadden A, Mason F, Baker J, et al. Spotlight on infant formula: coordinated global

action needed. The Lancet. 2016; 387(10017): 413–5. doi: 10.1016/S0140–

6736(16)00103–3

2. Goldman AS. Evolution of immune functions of the mammary gland and protection of

the infant. Breastfeeding Medicine: The Official Journal of the Academy of

Breastfeeding Medicine. 2012; 3(7): 132–42. doi: 10.1089/bfm.2012.0025

3. Victora CG, Bahl R, Barros A J, et al. Breastfeeding in the 21st century: epidemiology,

mechanisms, and lifelong effect. The Lancet. 2016; 387(10017): 475–90. doi:

10.1016/S0140–6736(15)01024–7

4. Eidelman AI, Schanler RJ, Johnston M, et al. Breastfeeding and the use of human milk.

Pediatrics. 2012; 129(3): e827–41. doi: 10.1542/peds.2011–3552.

5. World Health Organisation. (2011). Exclusive breastfeeding for six months best for

babies everywhere. Retrieved 03/15/2019, from

https://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/

6. The Scottish government. (2017). Scottish maternal and infant nutrition survey.

Retrieved 03/15/2019, from https://www.gov.scot/publications/scottish-maternal-

infant-nutrition-survey–2017/pages/0/

7. Nakamura M, Asaka Y, Ogawara T, et al. Nipple Skin Trauma in Breastfeeding Women

18
 During Postpartum Week One. Breastfeeding Medicine. 2018; 13(7): 479–84. doi:

10.1089/bfm.2017.0217

8. Kent J C, Ashton E, Hardwick CM, Rowan MK, et al. Nipple pain in breastfeeding

mothers: incidence, causes and treatments. International journal of environmental

research and public health. 2015; 12(10): 12247–63. doi: 10.3390/ijerph121012247

9. Brand E, Kothari C, Stark M A. Factors related to breastfeeding discontinuation

between hospital discharge and 2 weeks postpartum. The Journal of Perinatal

Education. 2011; 20(1): 36–44. doi: 10.1891/1058–1243.20.1.36.

10. Blair A, Caldwell K, Turner-maffei C, et al. The relationship between positioning, the

breastfeeding dynamic, the latching process and pain in breastfeeding mothers with

sore nipples. Breastfeeding Review: Professional Publication of the Nursing Mothers’

Association of Australia. 2003; 11(2): 5–10.

11. Brown A, Rance J, Bennett P. Understanding the relationship between breastfeeding

and postnatal depression: The role of pain and physical difficulties. Journal of

Advanced Nursing. 2016; 72(2): 273–82. doi: 10.1111/jan.12832

12. Jardine EE, McLellan J, Dombrowski SU. Is being resolute better than being pragmatic

when it comes to breastfeeding? longitudinal qualitative study investigating

experiences of women intending to breastfeed using the theoretical domains

framework. Journal of Public Health. 2016; 39(3): e88-e94. doi:

10.1093/pubmed/fdw073

13. Smith E. If It’s Natural, Why Does it Hurt? Examining the Reasons Mom May Feel Pain

with Breastfeeding. International Journal of Childbirth Education. 2016; 31(4): 40–3.

14. Jackson KT, Mantler T, O’Keefe-McCarthy S. Women’s Experiences of Breastfeeding-

Related Pain. MCN: The American Journal of Maternal/Child Nursing. 2019; 44(2): 66–

72. doi: 10.1097/NMC.0000000000000508.

19
15. Bhat AV, Raddi SA, Sawant P. Breastfeeding techniques among Primiparous women.

International Journal of Nursing Education. 2019; 11(1): 13–16.

16. Charette C, Théroux L. Musculoskeletal Impairment: Causes of Pain with

Breastfeeding Insight into 11 Cases. Breastfeeding Medicine. 2019. doi:

http://doi.org/10.1089/bfm.2019.0047

17. Burns E, Schmied V, Sheehan A, et al. A meta‐ethnographic synthesis of women’s

experience of breastfeeding. Maternal and Child Nutrition. 2010; 6(3): 201–19. doi:

10.1111/j.1740–8709.2009.00209.x.

18. Cortés-Rúa L, Díaz-Grávalos GJ. Early interruption of breastfeeding. A qualitative

study. Enfermeria Clinica (English Edition). 2019; 29(4):207–15. doi:

10.1016/j.enfcli.2018.11.003

19. Hauck YL, Irurita VF. Incompatible expectations: The dilemma of breastfeeding

mothers. Health Care for Women International. 2003; 24(1): 12–78. doi:

10.1080/07399330390170024

20. McInnes RJ, Chambers JA. Supporting breastfeeding mothers: qualitative

synthesis. Journal of advanced nursing. 2008; 62(4): 407–27. doi: 10.1111/j.1365–

2648.2008.04618

21. Fox R, McMullen S, Newburn M. UK women’s experiences of breastfeeding and

additional breastfeeding support: A qualitative study of baby café services. BMC

Pregnancy and Child Birth. 2015; 15(1): 147–59. doi: 10.1186/s12884–015–0581–5.

22. Lumbiganon P, Martis R, Laopaiboon M, et al. Antenatal breastfeeding education for

increasing breastfeeding duration. Cochrane Database of Systematic Reviews. 2016;

(12). doi: 10.1002/14651858.CD006425

23. Plantin L, Daneback K. Parenthood, information and support on the internet. A

literature review of research on parents and professionals online. BMC Family

20
 Practice. 2009; 10(1): 34. doi: 10.1186/1471–2296–10–34

24. Dworkin J, Rudi J, Doty J. A literature review of parents’ online behavior.

Cyberpsychology. 2013; 7(2). doi: 10.5817/CP2013–2–2

25. Drentea P, Moren‐Cross JL. Social capital and social support on the web: the case of

an internet mother site. Sociology of health & illness. 2005; 27(7): 920–43.

26. Bridges N, Howell G, Schmied V. Exploring breastfeeding support on social media.

International breastfeeding journal. 2018; 13(1): 22.

27. Niazi A, Rahim VB, Soheili-Far S, et al. A Systematic Review on Prevention and

Treatment of Nipple Pain and Fissure: Are They Curable?. Journal of

Pharmacopuncture. 2018; 21(3): 139.

28. Netmums. https://www.netmums.com. Accessed July 2018

29. Mumsnet. https://www.mumsnet.com. Accessed July 2018

30. What to Expect. https://www.whattoexpect.com. Accessed July 2018

31. Caes L, Jordan, A. The pain of youth. The British Psychological Society. 2017;

30(1):24–7.

32. Richard L. Are breastfeeding problems related to incorrect breastfeeding technique

and the use of pacifiers and bottles? Birth (Berkeley, Calif). 1998; 25(1): 40–4.

33. Dennis CL, Hodnett E, Gallop R, et al. The effect of peer support on breast-feeding

duration among primiparous women: A randomized controlled trial. CMAJ: Canadian

Medical Association Journal. 2002; 166(1): 21–8.

34. Ayton JE, Tesch L, Hansen E. Women’s experiences of ceasing to breastfeed:

Australian qualitative study. 2019; BMJ open: 9(5). doi: 10.1136/bmjopen–2018–

026234

35. Fahy E, Hardikar R, Fox A, et al. Quality of patient health information on the internet:

Reviewing a complex and evolving landscape. The Australasian Medical Journal.

21
 2014; 7(1): 24–8. doi: 10.4066/AMJ.2014.1900

36. Sbaffi L, Rowley J. Trust and credibility in web-based health information: A review

and agenda for future research. Journal of Medical Internet Research. 2017; 19(6):

e218. doi: 10.2196/jmir.7579.

37. Kohut SA, Stinson, J, van Wyk, M, Giosa, L, Luca S,. Systematic review of peer

support interventions for adolescents with chronic illness. Int J Child Adol Health.

2014; 7(3): 183–97.

38. Milgrom, J., Schembri, C., Ericksen, J, et al. Towards parenthood: An antenatal

intervention to reduce depression, anxiety and parenting difficulties. Journal of

Affective Disorders. 2011; 130(3): 385–94. doi: 10.1016/j.jad.2010.10.045.

Tables
Table 1. Themes, sub-themes and descriptions of the data extracted
Theme Description
Variation in types of pain Different types of pain that women
experienced and referred to throughout
their experience of breastfeeding
Perceived causes and explanations for Interpretations and reasons why women
pain may be experiencing different types of
pain
Cessation of breastfeeding related to Reasons and struggles, related to pain,
pain why women consider stopping
breastfeeding
Shared experiences and support Types of support, experiences and
knowledge that women provide to
support other women on their
breastfeeding journey
Sub-themes
- Pain location
- Sensory and emotional aspect of p
- Physical process associated with th
- Recognised condition
- Behavioural explanations
- Physical aspects
- Psychological aspects
- Sharing experiences
- Practical support
- Experience and support from healt
professionals

22